Aims

The aims of this study were to determine the success of a reconstruction algorithm used in major acetabular bone loss, and to further define the indications for custom-made implants in major acetabular bone loss.

Aims

Pelvic discontinuity is a challenging acetabular defect without a consensus on surgical management. Cup-cage reconstruction is an increasingly used treatment strategy. The present study evaluated implant survival, clinical and radiological outcomes, and complications associated with the cup-cage construct.

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Proximal femoral endoprosthetic replacements (PFEPRs) are the most common reconstruction option for osseous defects following primary and metastatic tumour resection. This study aimed to compare the rate of implant failure between PFEPRs with monopolar and bipolar hemiarthroplasties and acetabular arthroplasties, and determine the optimum articulation for revision PFEPRs.

Aims

Bone stock restoration of acetabular bone defects using impaction bone grafting (IBG) in total hip arthroplasty may facilitate future re-revision in the event of failure of the reconstruction. We hypothesized that the acetabular bone defect during re-revision surgery after IBG was smaller than during the previous revision surgery. The clinical and radiological results of re-revisions with repeated use of IBG were also analyzed.

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Conservative treatment of moderately displaced proximal humeral head fractures yields good clinical results, but secondary fragment displacement may occur. Identification of those fractures at risk of displacement may influence initial decision-making.

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Iliac wing (Type I) and iliosacral (Type I/IV) pelvic resections for a primary bone tumour create a large segmental defect in the pelvic ring. The management of this defect is controversial as the surgeon may choose to reconstruct it or not. When no reconstruction is undertaken, the residual ilium collapses back onto the remaining sacrum forming an iliosacral pseudarthrosis. The aim of this study was to evaluate the long-term oncological outcome, complications, and functional outcome after pelvic resection without reconstruction.

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In order to determine whether and for whom serial radiological evaluation is necessary in one-part proximal humerus fractures, we set out to describe the clinical history and predictors of secondary displacement in patients sustaining these injuries.

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The advent of trabecular metal (TM) augments has revolutionized the management of severe bone defects during acetabular reconstruction. The purpose of this study was to evaluate patients undergoing revision total hip arthroplasty (THA) with the use of TM augments for reconstruction of Paprosky IIIA and IIIB defects.

Aims. Dislocation rates are reportedly lower in patients requiring proximal femoral hemiarthroplasty than for patients undergoing hip arthroplasty for neoplasia. Without acetabular replacement, pain due to acetabular wear necessitating revision surgery has been described. We aimed to determine whether wear of the native acetabulum following hemiarthroplasty necessitates revision surgery with secondary replacement of the acetabulum after proximal femoral replacement (PFR) for tumour reconstruction. Patients and Methods. We reviewed 100 consecutive PFRs performed between January 2003 and January 2013 without acetabular resurfacing. The procedure was undertaken in 74 patients with metastases, for a primary bone tumour in 20 and for myeloma in six. There were 48 male and 52 female patients, with a mean age of 61.4 years (19 to 85) and median follow-up of two years (interquartile range (IQR) 0.5 to 3.7 years). In total, 52 patients presented with a pathological fracture and six presented with failed fixation of a previously instrumented pathological fracture. Results. All patients underwent reconstruction with either a unipolar (n = 64) or bipolar (n = 36) articulation. There were no dislocations and no acetabular resurfacings. Articular wear was graded using the criteria of Baker et al from 0 to 3, where by 0 is normal; grade 1 represents a narrowing of articular cartilage and no bone erosion; grade 2 represents acetabular bone erosion and early migration; and grade 3 represents protrusio acetabuli. Of the 49 patients with radiological follow-up greater than one year, six demonstrated grade 1 acetabular wear and two demonstrated grade 2 acetabular wear. The remainder demonstrated no radiographic evidence of wear. Median medial migration was 0.3 mm (IQR -0.2 to 0.7) and superior migration was 0.3 mm (IQR -0.2 to 0.6). No relationship between unipolar versus bipolar articulations and wear was evident. Conclusion. Hemiarthroplasty PFRs for tumour reconstruction eliminate joint instability and, in the short to medium term, do not lead to native acetabular wear necessitating later acetabular resurfacing. Cite this article: Bone Joint J 2018;100B:101–8

Aims

The purpose of this study was to determine the sensitivity, specificity and predictive values of previously reported thresholds of proximal translation and sagittal rotation of cementless acetabular components used for revision total hip arthroplasty (THA) at various times during early follow-up.

Periprosthetic fractures are an increasingly common complication following joint replacement. The principles which underpin their evaluation and treatment are common across the musculoskeletal system. The Unified Classification System proposes a rational approach to treatment, regardless of the bone that is broken or the joint involved.

Cite this article: Bone Joint J 2014;96-B:713–16.

The use of ilioischial cage reconstruction for pelvic discontinuity has been replaced by the Trabecular Metal (Zimmer, Warsaw, Indiana) cup-cage technique in our institution, due to the unsatisfactory outcome of using a cage alone in this situation. We report the outcome of 26 pelvic discontinuities in 24 patients (20 women and four men, mean age 65 years (44 to 84)) treated by the cup-cage technique at a mean follow-up of 82 months (12 to 113) and compared them with a series of 19 pelvic discontinuities in 19 patients (18 women and one man, mean age 70 years (42 to 86)) treated with a cage at a mean follow-up of 69 months (1 to 170). The clinical and radiological outcomes as well as the survivorship of the groups were compared. In all, four of the cup-cage group (15%) and 13 (68%) of the cage group failed due to septic or aseptic loosening. The seven-year survivorship was 87.2% (95% confidence interval (CI) 71 to 103) for the cup-cage group and 49.9% (95% CI 15 to 84) for the cage-alone group (p = 0.009). There were four major complications in the cup-cage group and nine in the cage group. Radiological union of the discontinuity was found in all successful cases in the cup-cage group and three of the successful cage cases. Three hips in the cup-cage group developed early radiological migration of the components, which stabilised with a successful outcome.

Cup-cage reconstruction is a reliable technique for treating pelvic discontinuity in mid-term follow-up and is preferred to ilioischial cage reconstruction. If the continuity of the bone graft at the discontinuity site is not disrupted, early migration of the components does not necessarily result in failure.

Cite this article: Bone Joint J 2014;96-B:195–200.

There are few reports describing the technique of managing acetabular protrusio in primary total hip replacement. Most are small series with different methods of addressing the challenges of significant medial and proximal migration of the joint centre, deficient medial bone and reduced peripheral bony support to the acetabular component. We describe our technique and the clinical and radiological outcome of using impacted morsellised autograft with a porous-coated cementless cup in 30 primary THRs with mild (n = 8), moderate (n = 10) and severe (n = 12) grades of acetabular protrusio. The mean Harris hip score had improved from 52 pre-operatively to 85 at a mean follow-up of 4.2 years (2 to 10). At final follow-up, 27 hips (90%) had a good or excellent result, two (7%) had a fair result and one (3%) had a poor result. All bone grafts had united by the sixth post-operative month and none of the hips showed any radiological evidence of recurrence of protrusio, osteolysis or loosening. By using impacted morsellised autograft and cementless acetabular components it was possible to achieve restoration of hip mechanics, provide a biological solution to bone deficiency and ensure long-term fixation without recurrence in arthritic hips with protrusio undergoing THR.

Cite this article: Bone Joint J 2013;95-B, Supple A:37–40.

It is probable that both genetic and environmental factors play some part in the aetiology of most cases of degenerative hip disease. Geneticists have identified some single gene disorders of the hip, but have had difficulty in identifying the genetics of many of the common causes of degenerative hip disease. The heterogeneity of the phenotypes studied is part of the problem. A detailed classification of phenotypes is proposed. This study is based on careful documentation of 2003 consecutive total hip replacements performed by a single surgeon between 1972 and 2000. The concept that developmental problems may initiate degenerative hip disease is supported. The influences of gender, age and body mass index are outlined. Biomechanical explanations for some of the radiological appearances encountered are suggested. The body weight lever, which is larger than the abductor lever, causes the abductor power to be more important than body weight. The possibility that a deficiency in joint lubrication is a cause of degenerative hip disease is discussed. Identifying the phenotypes may help geneticists to identify genes responsible for degenerative hip disease, and eventually lead to a definitive classification.

The purpose of this study was to review the long-term outcomes of a previously reported prospective series of 46 type III acromioclavicular dislocations. These were treated surgically with temporary fixation of the acromioclavicular joint with wires, repair of the acromioclavicular ligaments, and overlapped suture of the deltoid and trapezius muscles. Of the 46 patients, one had died, four could not be traced, and three declined to return for follow-up, leaving 38 patients in the study. There were 36 men and two women, with a mean age at follow-up of 57.3 years (41 to 71). The mean follow-up was 24.2 years (21 to 26).

Patients were evaluated using the Imatani and University of California, Los Angeles (UCLA) scoring systems. Their subjective status was assessed using the Disabilities of the Arm, Shoulder and Hand and Simple Shoulder Test questionnaires, and a visual analogue scale for patient satisfaction. The examination included radiographs of the shoulder.

At a follow-up of 21 years, the results were satisfactory in 35 (92.1%) patients and unsatisfactory in three (7.9%). In total, 35 patients (92.1%) reported no pain, one slight pain, and two moderate pain. All except two patients had a full range of shoulder movement compared with the opposite side. Unsatisfactory results were the result of early redisplacement in two patients, and osteoarthritis without redisplacement in one. According to the Imatani and UCLA scores, there was no difference between the operated shoulder and the opposite shoulder (p > 0.05). Given the same situation, 35 (92.1%) patients would opt for the same surgical treatment again.

Operative treatment of type III acromioclavicular joint injuries produces satisfactory long-term results.

We have investigated the mid-term outcome of total shoulder replacement using a keeled cemented glenoid component and a modern cementing technique with regard to the causes of failure and loosening of the components.

Between 1997 and 2003 we performed 96 total shoulder replacements on 88 patients, 24 men and 64 women with a mean age of 69.7 years (31 to 82). The minimum follow-up was five years and at the time of review 87 shoulders (77 patients) were examined at a mean follow-up of 89.1 months (60 to 127). Cumulative survival curves were generated with re-operations (accomplished and planned), survivorship of the proshesis, loosening of the glenoid (defined as tilt > 5° or subsidence > 5 mm), the presence of radiolucent lines and a Constant score of < 30 as the endpoints.

There were two re-operations not involving revision of the implants and the survival rate of the prosthesis was 100.0% for the follow-up period, with an absolute Constant score of > 30 as the endpoint the survival rate was 98%. Radiological glenoid loosening was 9% after five years, and 33% after nine years. There was an incidence of 8% of radiolucent lines in more than three of six zones in the immediate post-operative period, of 37.0% after the first year which increased to 87.0% after nine years. There was no correlation between the score of Boileau and the total Constant score at the latest follow-up, but there was correlation between glenoid loosening and pain (p = 0.001).

We found that total shoulder replacement had an excellent mid-term survivorship and clinical outcome. The surgical and cementing techniques were related to the decrease in radiolucent lines around the glenoid compared with earlier studies. One concern, however, was the fact that radiolucent lines increased over time and there was a rate of glenoid loosening of 9% after five years and 33% after nine years. This suggests that the design of the glenoid component, and the implantation and cementing techniques may need further improvement.

We describe a technique to salvage a painful hemiarthroplasty due to erosion of the acetabular cartilage in the absence of loosening of the femoral component. A press-fit metallic acetabular component which matched the femoral component was used as a metal-on-metal articulation. The procedure offered a shorter operation time with less blood loss and no risk of femoral fracture as might have occurred during conventional revision to a total hip replacement. The patient made an unremarkable recovery with a good outcome at follow-up of 15 months.

Between 1976 and 2004, 38 revision arthroplasties (35 patients) were performed for aseptic loosening of the humeral component. The mean interval from primary arthroplasty to revision was 7.1 years (0.4 to 16.6). A total of 35 shoulders (32 patients) were available for review at a mean follow-up of seven years (2 to 19.3).

Pre-operatively, 34 patients (97%) had moderate or severe pain; at final follow-up, 29 (83%) had no or only mild pain (p < 0.0001). The mean active abduction improved from 88° to 107° (p < 0.01); and the mean external rotation from 37° to 46° (p = 0.27). Excellent or satisfactory results were achieved in 25 patients (71%) according to the modified Neer rating system. Humeral components were cemented in 29, with ingrowth implants used in nine cases. There were 19 of standard length and 17 were longer (two were custom replacements and are not included). Bone grafting was required for defects in 11 humeri. Only two glenoid components were left unrevised. Intra-operative complications included cement extrusion in eight cases, fracture of the shaft of the humerus is two and of the tuberosity in four. There were four re-operations, one for recurrent humeral loosening, with 89% survival free of re-operations at ten years.

Revision surgery for aseptic loosening of the humeral component provides reliable pain relief and modest improvement of movement, although there is a substantial risk of intra-operative complications. Revision to a total shoulder replacement gives better results than to a hemiarthroplasty.

Migration of the acetabular component may give rise to oval-shaped bone defects in the acetabulum. The oblong implant is designed to fill these defects and achieve a stable cementless anchorage with no significant bone loss. We prospectively reviewed 133 oblong long oblique revision components at a mean follow-up of 9.74 years (0.6 to 14). All had been used in revisions for defects of type IIB to IIIB according to Paprosky. Aseptic loosening was the reason for revision in 11 cases (8.3%) and deep infection in seven (5.3%). The probability of implant survival over a 12-year follow-up estimated by the Kaplan-Meier method gave a survival rate of 0.85% respectively 0.90% when deep infection was excluded as the endpoint.

Our study supports the use of these components in defects from IIB to IIIA. The main precondition for success is direct contact of more than half of the surface of the implant with the host acetabular bone.

We treated 98 patients with peri-acetabular tumours by resection and reconstruction with a custom-made pelvic endoprosthesis. The overall survival of the patients was 67% at five years, 54% at ten years and 51% at 30 years. One or more complications occurred in 58.1% of patients (54), of which infection was the most common, affecting 30% (28 patients). The rate of local recurrence was 31% (29 patients) after a mean follow-up of 71 months (11 to 147). Dislocation occurred in 20% of patients (19). Before 1996 the rate was 40.5% (17 patients) but this was reduced to 3.9% (two patients) with the introduction of a larger femoral head. There were six cases of palsy of the femoral nerve with recovery in only two. Revision or excision arthroplasty was performed in 23.7% of patients (22), principally for uncontrolled infection or aseptic loosening. Higher rates of death, infection and revision occurred in men.

This method of treatment is still associated with high morbidity. Patients should be carefully selected and informed of this pre-operatively.